Fill and Sign the New York Workers Compensation Form

                                                                       RIGHT TO COMPENSATION IS NOT DISPUTED. PAYMENT HAS RESUMED.       at a weekly rate of $                   TEMPORARY PAYMENT HAS BEGUN WITHOUT PREJUDICE AND WITHOUT ADMITTING LIABILITY (Sec. 21-a WCL)       at a weekly rate of $             RIGHT TO COMPENSATION IS NOT DISPUTED. NECESSARY MEDICAL TREATMENT AUTHORIZED. RIGHT TO COMPENSATION IS NOT DISPUTED. PAYMENT HAS NOT BEGUN. Reasons must be stated below.       RIGHT TO COMPENSATION IS DISPUTED. Reasons must be stated above. (Attach supporting medical report if reason is Prepared by       Official Title                         CHECK TYPE OF CASE: WORKERS' COMPENSATION VOLUNTEER FIREFIGHTER VOLUNTEER AMBULANCE WORKER ANSWER ALL QUESTIONS FULLY - TYPEWRITER OR COMPUTER PREPARATION IS REQUIRED ALL COMMUNICATIONS SHOULD REFER TO THESE NUMBERS 1. WCB Case Number 2. Carrier Case Number 3. Carrier Code 4. Date of Injury 5. Social Security Number Name Address to which notices should be sent 6. Injured Person 7. Employer* 8. Carrier • In volunteer firefighters' and volunteer ambulance workers' cages, enter the liable political subdivision (or unaffiliated ambulance service as defined in VAWBL) as the EMPLOYER 9. A. Payment has resumed from (If less than rate previously established by the Board for most recent period of disability, explain below.) Date of first payment Compensation shall be payable from until notice is given to the Chair that payment has been stopped or modified. B. Payment has resumed from (If less than rate previously established by the Board for most recent period of disability, explain below.) Date of first payment C. No payments due. Explain below. 10. Use this space for stating the reasons for not beginning payment in uncontroverted cases, or reasons for controverting in controverted cases, or to explain payment at less than previously established rate. 11. that disability is not causally related.)Dated Telephone No. & Extension SEE IMPORTANT INFORMATION TO CLAIMANT AND CARRIER ON REVERSE. (5-99) Prescribed by ChairWorkers' Compensation BoardState of New York RB-679 RB-679 RB-679 RB-679 RB-679 RB-679 This notice must be filed by the Insurance Carrier or Self-Insured Employer or the Self-Insured Political Subdivision or Unaffiliated Volunteer Ambulance Service with the Chair, Workers' Compensation Board, c/o Review Bureau, Room 504, 180 Livingston Street, Brooklyn, NY 11248, within 25 days after receiving an application to reopen a case previously established and closed by the Board. If the employer becomes aware that a claimant whose case has previously been established and closed by the Board has begun to lose additional time, the employer or carrier may begin temporary payments of compensation immediately. In accordance with 12 NYCRR 300.22 (see below), a copy of this notice must also be mailed to the claimant and to his/her representative, if any, simultaneously with its filing with the Chair FAILURE TO COMPLETE THIS FORM IN FULL MAY BE CONSTRUED AS NOT SATISFYING THE REQUIREMENTS OF THE LAW 12 NYCRR 300.22 Subdivision e (e) Except as provided in subdivision (d) of this section, the following procedures and forms shall apply when there is an application by a claimant to reopen a case previously established and closed by the board. Pursuant to Section 300. 15 (b) of this part, when the claimant makes an application to reopen a case previously established and is represented by an attorney or licensedrepresentative, such attorney or licensed representative shall on the same day mail a copy of the application to the employer or carrier, When the claimant makes such application and is not represented by an attorney or licensed representative, the chair, upon receipt of the application, shall mail a copy of the application to the employer or its carrier. An employer or its carrier shall rile prescribed form RB-679 with the chair within 25 days after the employer or its carrier receives an application to reopen a case previously established and dosed by the board. The employer or its carrier shall indicate on the form whether payment for compensation and/or medical treatment has commenced, the claim is controverted, or the claim is not controverted but payment has not begun. When a claim is controverted or payment has not begun in an uncontroverted claim, the reason or reasons therefor shall clearly be stated on the form. A copy of form RB-679 must be mailed by the employer or its carrier to the claimant and his or her attorney or licensed representative, if any, simultaneously with the filing with the chair. An employer or carrier which fails to comply with the requirements of this subdivision s I be subject to penalties pursuant to Section 25 of the Workers' Compensation Law. [Emphasis added.] TO THE CLAIMANT IF ITEM 9-A IS CHECKED , your employer or its insurance carrier has begun the payment of benefits to you voluntarily without waiting for an award by the Workers' Compensation Board. Payment of benefits will be made to you every two weeks (unless otherwise approved by the Board) at the rate shown in item 9-A on the other side of this form, until your employer serves notice on you and the Board, on Form C-8/8.6 that such payments are being stopped or modified for reasons which will be stated on Form C-8/8.6. At an appropriate time thereafter, the Board will schedule your case for a hearing before a WC Law Judge to determine if benefits have been fully paid and for whatever other action is required. IF ITEM 9-B IS CHECKED your employer or its insurance carrier has started to pay temporary benefits to you without admitting liability for your claim. Such payments may continue for up to one year or until your employer or its carrier notifies you and the Board, on Form C-8/8.6, that payments are being stopped. The Board will then notify you in writing of any further action taken in your claim. This payment is not an admission of liability by the employer or carrier for your injury or injuries. You may be required to enter into an agreement with the employer or carrier to ensure continuation of payment of temporary compensation. IF ITEM 9-C IS CHECKED , your employer or its insurance carrier has authorized necessary medical treatment in your case, but contends that benefit payments are not due for the reasons stated. If you disagree with the reasons given, notify the Workers' Compensation Board, Review Bureau, immediately. IF ITEM 10 IS CHECKED , your employer or its insurance carrier does not now dispute your application for reopening, but has not begun the payment of benefits for the reasons show. In other words, while no other questions are being raised at this time concerning your application, it is contended that benefits are not now due you, either because you have not lost sufficient time from work, or are receiving your wages during disability, or because medical proof of your disability is lacking, or for such reasons as are stated. Depending on the reasons for non-payment given on the other side of this notice, and all other reports in its possession concerning your case, the Board may schedule your case for a hearing before a WC Law Judge to determine if benefits are payable to you for a compensable period of disability. IF ITEM 11 IS CHECKED , your employer or its insurance company is disputing your entitlement to benefits in connection with the application for reopening indicated on the other side of this notice, for the reasons stated. The Workers' Compensation Board will schedule your case for a hearing before a WC Law Judge as quickly as possible, so that the issues raised by your employer or its insurance carrier may be considered and a decision reached on your right to such benefits. ATTEND THE HEARING WHEN YOU ARE NOTIFIED TO APPEAR. IF YOU HAVE ANY QUESTIONS CONCERNING THIS NOTICE OR YOUR CASE, OR WITH RESPECT TO YOUR RIGHTS UNDER THE WORKERS'COMPENSATION LAW, OR THE VOLUNTEER FIREFIGHTERS VOLUNTEER AMBULANCE WORKERS OR DISABILITY BENEFITS LAWS, YOUSHOULD CONSULT THE NEAREST OFFICE OF THE BOARD FOR ADVICE. ALWAYS USE THE CASE NUMBERS SHOWN ON THE OTHER SIDE OFTHIS NOTICE, OR ON OTHER PAPERS RECEIVED BY YOU, IF YOU FIND IT NECESSARY TO WRITE OR CALL THE BOARD. TO THE CARRIER; Section 114 of the Workers' Compensation Law, as amended by Chapter 635 of the Laws of 1996, provides, in part, that any employer or carrier which knowingly makes a false statement or representation as to a material fact for the purpose of avoiding provision of any payment or benefit under this chapter shall be guilty of a felony. RB-679 (5-99) Reverse Page 2Last page